GINA 2014 DR TRÌNH THỊ NGÀ G lobal INitiative for A sthma © Global Initiative for Asthma INTRODUCTION       Definition and diagnosis of asthma Assessment of asthma Treating asthma to control symptoms and minimize risk Asthma flare-ups (exacerbations) Diagnosis and management of asthma in children years and younger Primary prevention of asthma GINA Strategy - major revision 2014  New chapters  Management of asthma in children years and younger, previously published separately in 2009  Diagnosis of asthma-COPD overlap (ACOS): a joint project of GINA and GOLD GINA 2014 Burden of asthma     GINA 2014 Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals Prevalence is increasing in many countries, especially in children Asthma is a major cause of school and work absence Health care expenditure on asthma is very high Definition of asthma Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation NEW! GINA 2014 Diagnosis of asthma  The diagnosis of asthma should be based on:    Document evidence for the diagnosis in the patient’s notes, preferably before starting controller treatment   GINA 2014 A history of characteristic symptom patterns Evidence of variable airflow limitation, from bronchodilator reversibility testing or other tests It is often more difficult to confirm the diagnosis after treatment has been started Asthma is usually characterized by airway inflammation and airway hyperresponsiveness, but these are not necessary or sufficient to make the diagnosis of asthma NEW! GINA 2014, Box 1-1 © Global Initiative for Asthma Diagnosis of asthma – variable airflow limitation  Confirm presence of airflow limitation    Document that FEV1/FVC is reduced (at least once, when FEV1 is low) FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and >0.90 in children Confirm variation in lung function is greater than in healthy individuals      The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted) Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged) Significant increase in FEV1 or PEF after weeks of controller treatment If initial testing is negative:   GINA 2014, Box 1-2 Repeat when patient is symptomatic, or after withholding bronchodilators Refer for additional tests (especially children ≤5 years, or the elderly) Typical spirometric tracings Volume Flow Normal FEV1 Asthma (after BD) Normal Asthma (before BD) Asthma (after BD) Asthma (before BD) Volume Time (seconds) Note: Each FEV1 represents the highest of three reproducible measurements GINA 2014 © Global Initiative for Asthma Stepwise approach to control asthma symptoms and reduce risk NEW! GINA 2014, Box 3-5 © Global Initiative for Asthma Low, medium and high dose inhaled corticosteroids Adults and adolescents (≥12 years) Inhaled corticosteroid Total daily dose (mcg) Low Medium High Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000 Beclometasone dipropionate (HFA) 100–200 >200–400 >400 Budesonide (DPI) 200–400 >400–800 >800 Ciclesonide (HFA) 80–160 >160–320 >320 Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500 Mometasone furoate 110–220 >220–440 >440 400–1000 >1000–2000 >2000 Triamcinolone acetonide GINA 2014, Box 3-6 (1/2) Low, medium and high dose inhaled corticosteroids Children 6–11 years Inhaled corticosteroid Total daily dose (mcg) Low Medium High Beclometasone dipropionate (CFC) 100–200 >200–400 >400 Beclometasone dipropionate (HFA) 50–100 >100–200 >200 Budesonide (DPI) 100–200 >200–400 >400 Budesonide (nebules) 250–500 >500–1000 >1000 80 >80–160 >160 Fluticasone propionate (DPI) 100–200 >200–400 >400 Fluticasone propionate (HFA) 100–200 >200–500 >500 110 ≥220–800–1200 >1200 Ciclesonide (HFA) Mometasone furoate Triamcinolone acetonide GINA 2014, Box 3-6 (2/2) Reviewing response and adjusting treatment  How often should asthma be reviewed?  1-3 months after treatment started, then every 312 months  During pregnancy, every 4-6 weeks  After an exacerbation, within week Managing exacerbations in primary care NEW! GINA 2014, Box 4-3 (1/3) © Global Initiative for Asthma Diagnosis and management of asthma in children years and younger © Global Initiative for Asthma Probability of asthma diagnosis or response to asthma treatment in children ≤5 years GINA 2014, Box 6-1 (1/2) © Global Initiative for Asthma Features suggesting asthma in children ≤5 years Feature Characteristics suggesting asthma Cough Recurrent or persistent non-productive cough that may be worse at night or accompanied by some wheezing and breathing difficulties Cough occurring with exercise, laughing, crying or exposure to tobacco smoke in the absence of an apparent respiratory infection Wheezing Recurrent wheezing, including during sleep or with triggers such as activity, laughing, crying or exposure to tobacco smoke or air pollution Difficult or heavy breathing or shortness of breath Occurring with exercise, laughing, or crying Reduced activity Not running, playing or laughing at the same intensity as other children; tires earlier during walks (wants to be carried) Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis) Asthma in first-degree relatives Therapeutic trial with low dose ICS and as-needed SABA Clinical improvement during 2–3 months of controller treatment and worsening when treatment is stopped GINA 2014, Box 6-2 © Global Initiative for Asthma Stepwise approach – pharmacotherapy (children ≤5 years) GINA 2014, Box 6-5 © Global Initiative for Asthma © Global Initiative for Asthma ‘Low dose’ inhaled corticosteroids (mcg/day) for children ≤5 years Inhaled corticosteroid Low daily dose (mcg) Beclometasone dipropionate (HFA) 100 Budesonide (pMDI + spacer) 200 Budesonide (nebulizer) 500 Fluticasone propionate (HFA) 100 Ciclesonide 160 Mometasone furoate Triamcinolone acetonide GINA Box6-6 6-6 GINA2014, 2014, Box Not studied below age years Not studied in this age group Initial assessment of acute asthma exacerbations in children ≤5 years Symptoms Mild Severe* Altered consciousness No Agitated, confused or drowsy Oximetry on presentation (SaO2)** >95% 180 beats/min (4–5 years) Central cyanosis Absent Likely to be present Wheeze intensity Variable Chest may be quiet Speech† Pulse rate *Any of these features indicates a severe exacerbation **Oximetry before treatment with oxygen or bronchodilator † Take into account the child’s normal developmental capability GINA 2014, Box 6-8 © Global Initiative for Asthma Initial management of asthma exacerbations in children ≤5 years Therapy Dose and administration Supplemental oxygen 24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 94-98% Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every 20 for first hour, then reassess severity If symptoms persist or recur, give an additional 2-3 puffs per hour Admit to hospital if >10 puffs required in 3-4 hours Systemic corticosteroids Give initial dose of oral prednisolone (1-2mg/kg up to maximum of 20mg for children [...]...Assessment of asthma © Global Initiative for Asthma GINA assessment of asthma control GINA 2014, Box 2-2A © Global Initiative for Asthma GINA assessment of asthma control GINA 2014, Box 2-2B © Global Initiative for Asthma Assessment of risk factors for poor asthma outcomes Risk factors for exacerbations include: • • • • Ever intubated for asthma Uncontrolled asthma symptoms Having ≥1 exacerbation... every 20 minutes for one hour only Magnesium sulfate Consider nebulized isotonic MgSO4 (150mg) 3 doses in first hour for children ≥2 years with severe exacerbation GINA 2014, Box 6-10 © Global Initiative for Asthma Primary prevention of asthma © Global Initiative for Asthma Primary prevention of asthma  The development and persistence of asthma are driven by gene-environment interactions  For children,... allergic rhinitis) Asthma in first-degree relatives Therapeutic trial with low dose ICS and as-needed SABA Clinical improvement during 2–3 months of controller treatment and worsening when treatment is stopped GINA 2014, Box 6-2 © Global Initiative for Asthma Stepwise approach – pharmacotherapy (children ≤5 years) GINA 2014, Box 6-5 © Global Initiative for Asthma © Global Initiative for Asthma ‘Low dose’... factors for fixed airflow limitation include: • No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia Risk factors for medication side-effects include: • Frequent oral steroids, high dose/potent ICS, P450 inhibitors GINA 2014, Box 2-2B © Global Initiative for Asthma Treating asthma to control symptoms and minimize risk © Global Initiative for Asthma Goals of asthma. .. asthma be reviewed?  1-3 months after treatment started, then every 312 months  During pregnancy, every 4-6 weeks  After an exacerbation, within 1 week Managing exacerbations in primary care NEW! GINA 2014, Box 4-3 (1/3) © Global Initiative for Asthma Diagnosis and management of asthma in children 5 years and younger © Global Initiative for Asthma Probability of asthma diagnosis or response to asthma. .. literacy The control-based asthma management cycle NEW! GINA 2014, Box 3-2 © Global Initiative for Asthma Initial controller treatment for adults, adolescents and children 6–11 years  Start controller treatment early  For best outcomes, initiate controller treatment as early as possible after making the diagnosis of asthma  Indications for regular low-dose ICS - any of:  Asthma symptoms more than... due to asthma more than once a month  Any asthma symptoms plus any risk factors for exacerbations NEW! GINA 2014, Box 3-4 (1/2) Initial controller treatment for adults, adolescents and children 6–11 years  Consider starting at a higher step if:  Troublesome asthma symptoms on most days  Waking from asthma once or more a week, especially if any risk factors for exacerbations  If initial asthma. .. Variable Chest may be quiet Speech† Pulse rate *Any of these features indicates a severe exacerbation **Oximetry before treatment with oxygen or bronchodilator † Take into account the child’s normal developmental capability GINA 2014, Box 6-8 © Global Initiative for Asthma Initial management of asthma exacerbations in children ≤5 years Therapy Dose and administration Supplemental oxygen 24% delivered by... younger © Global Initiative for Asthma Probability of asthma diagnosis or response to asthma treatment in children ≤5 years GINA 2014, Box 6-1 (1/2) © Global Initiative for Asthma Features suggesting asthma in children ≤5 years Feature Characteristics suggesting asthma Cough Recurrent or persistent non-productive cough that may be worse at night or accompanied by some wheezing and breathing difficulties Cough... steroids and start regular controller treatment (e.g high dose ICS or medium dose ICS/LABA, then step down) NEW! GINA 2014, Box 3-4 (1/2) Stepwise approach to control asthma symptoms and reduce risk NEW! GINA 2014, Box 3-5 © Global Initiative for Asthma Low, medium and high dose inhaled corticosteroids Adults and adolescents (≥12 years) Inhaled corticosteroid Total daily dose (mcg) Low Medium High Beclometasone